Allan Schore writes that the self-organisation of the developing brain occurs in relationship with another brain (Schore, 2019a). This relational environment can be growth-facilitating or growth inhibiting. It is this environment that imprints into the early developing right-brain either resilience or vulnerability to later developing psychiatric disorders. Borderline personality disorder, PTSD, and antisocial personality disorders are associated with early traumatic attachments that are ‘burnt into’ the right-brain. This impairs the regulatory capacities to cope effectively with stressors throughout the lifespan. Developmental science has shown the amazing plasticity and responsiveness of the developing brain to early enriched environments.
Understanding the ‘motivational basis’ of healthy and ‘at risk parenting’ can open clinical opportunities leading to the development of specific interventions that can target disruptions in the attachment bond earlier and in a more accurate way (Schore, 2019a). Regulation theory can be used as a guide to formulate assessments of the attachment relationship early in life and subsequent intervention and prevention work. Interpersonal neurobiology holds that the structure and function of the mind and brain are shaped by social experience, particularly emotional connections. Early assessment therefore focuses on the attachment relationship and the infant’s emerging capacity for intersubjectivity. There is an accepted principle that the biology of maternal behaviour is influenced by a mother’s past experience as well as their current circumstances. Therefore, the mother’s early experience with her own mother influences how she will regulate her infant.
Schore highlights here the importance of understanding ‘at risk parenting’ which can then offer insight into how to formulate targeted and specific interventions. In a world of limited resources, it is important to use those resources well. More services do not make children better – it is the quality of services that counts (Ungar, 2019). This does not mean we should provide less services but that we should provide ‘the right service, from the right people, in the right way’ (Ungar, 2019, p.23). To this we might add we need to provide the right intervention to the right person at the right time. Allan Schore’s detailed body of work provides a suitable heuristic for assessment and intervention that aim to break the cycle of the intergenerational transmission of risk.
Biological and interpersonal processes are involved in the intergenerational transmission of risk (Lieberman, 2020). ‘Foetal programming’ links prenatal stress to changes in foetal development and an increase in risk of developing psychiatric conditions later in life. Distress to pregnant women may influence foetal functioning by changes in placental gene DNA methylation. Parent’s childhoods and epigenetics are the first exposure in the intergenerational transmission of disadvantage. Maternal adversity, both before and during pregnancy affect the respiratory sinus arrythmia of the foetus – a marker of infant self-regulation which is linked to mental and physical health outcomes throughout life. Higher adverse childhood experiences (ACE’s) scores were linked with lower RSA. Maternal prenatal stress was fund to be associated with the failure of the infant to recover following the stressor of the still-face experiment. It is interesting to note here that it is not just stress during pregnancy that effects the infant but the whole history of maternal adversity. This highlights the need to decrease adversity for all throughout development (as well as increasing resources for coping).
Learning occurs in Utero between the mother and the foetus (Schore, 2019a). The emotional state of the mother impacts the foetus – the amount of cortisol that crosses the placenta influences the genetic system of the foetus. Current research shows that temperament at birth is the result of epigenetic processes that continue after birth. Developmental studies need to move further back to this primordial period, which has largely been ignored by science up to now.
Interpersonal violence, especially violence experienced by children is the largest single, preventable cause of mental illness (Liberman, 2020). Early childhood violence is the equivalent for mental health to smoking for physical health. This indicates that it is important to make it a key focus of therapeutic intervention. There is a large amount of evidence that show the success of interventions that start in pregnancy and continue after birth.
Many are exposed to interpersonal violence in utero, meaning that not even the womb is a safe haven (Schore, 2019a). High maternal cortisol in late pregnancy is linked with more difficult behaviour at birth. In weeks 1-7 these infants cry and fuss more and display negative facial expressions, often labelled as having a ‘difficult temperament’. It is not usually understood that birth has no significance for brain developmental sequence. There is a continuity of brain development in prenatal and postnatal periods which suggests the idea of inborn, temperament, present at birth, represents genetic factors is incorrect. Temperament at birth emerges through epigenetic mechanisms that develop prenatally and continue to be shaped postnatally.
Schore corrects here some misconceptions about ‘innate temperament’ – the foetus is being environmentally shaped in the womb and there is perhaps an under-appreciation of the importance of this ‘primordial’ environment. The importance of this period highlights the importance of beginning interventions in pregnancy rather than at birth. Stress is identified as potentially detrimental for development, but how much stress? Clearly chronic and acute stress or trauma is a problem but it seems unclear as to how much is too much.
In exploring risk factors for child maltreatment parents who have psychological disorders or addiction issues are at a higher risk (Belsky, 2019). Abusive parents are often young and poorly educated. They tend to be coping with a plethora of problems from poverty to domestic violence and feel cut off from caring connections, isolated in neighbourhoods with low collective efficacy. Children’s vulnerabilities that require extra care can fan the flames of this fire. Disturbances in the attachment relationship are a core ingredient in maltreatment.
Parents who were maltreated as children but did not maltreat their own children were more likely to have received emotional support from another non-abusive adult, and/or to have participated in a therapy experience that lasted longer than six months, at some point in their lives (Lieberman, 2020). Also, those who broke this cycle were often found to have a supportive mate in adulthood. All of these change-promoting factors involve relationships. Mothers who broke the cycle were found to be able to integrate past abusive experiences into a coherent sense of self. Mothers who re-enacted their maltreatment on their children had experienced more life stress and were more likely to be anxious, depressed, dependant and immature. These mothers had more dissociative symptoms and often recall their early experiences in a fragmented, idealised or unintegrated way. The ability to integrate early caregiving experiences is linked with positive parenting. Denial or the inability to integrate these experiences is linked with the re-enactment of harsh experiences.
The above authors highlight the importance of parental mental health in parenting. Trauma tends to be re-enacted and repeated (Bloom, 2013). However, it is clear that this cycle can be broken primarily through the experience of positive relational connections. This highlights the need to create these connections throughout the lifespan. Coupled with this, Lieberman highlights the importance of integrating past trauma and creating a coherent sense of self. Mothers with dissociative symptoms are higher risk and therefore a population that should be prioritised in intervention efforts.
The human brain growth spurt begins in the last trimester and continues to the third year (Schore, 2012). Day care provided by current American society increases the risk of insecure attachment when it begins in the first year and has an extensive duration. Nonmaternal and nonparental care in the first year is a risk for insecure attachment and insecure-avoidant infants who have received such care express more negative affect and upon reunion engage less in object play with the mother. Even infants who use in home baby-sitters for more than twenty hours per week show more avoidance upon reunion and are more likely to be classified as displaying insecure attachment. There has also been a link reported between early day care and aggression and noncompliance. Elevated insecure patterns are consistently found in child care children. Schore writes that caregiving is not just about the first few months but the first two years of life – ‘an essential problem for the future of human societies’ (Schore, 2012, p.362). Care initiated early in life and experienced for many hours, in particular in child care centres, is linked with higher levels of externalising behaviour problems. This is not simply the result of low-quality care. There has been shown to be a link between day care and elevated cortisol levels. Schore cites other authors who claim that the ‘stressful environment’ of day care is known to jeopardise children’s development. Early entry into day care interferes with the 6-month policy of breast feeding recommended by the American academy of paediatrics. Breast milk is a source of nutrients essential to the developing brain and research shows that shorter duration of breastfeeding may predict mental health problems throughout childhood and adolescence. Developmental difficulties may be the result of chronic stress which has a detrimental impact on brain activity, emotional development and well-being.
The research on day care is unsettling and problematic given its extensive use. It is likely that some of this is due to the ratios involved. Bruce Perry (in Narvaez et al, 2012) writes that in the modern world we raise and educate children in environments that are “oddly impoverished of complex somatosensory-rich, relational interactions (touching, holding, rocking or intergenerational contact). Humans evolved and lived hunter-gatherer small band (HGSB) groups in which the ratio of developmentally more mature people who could model, enrich, educate, nurture and protect a young child was 4:1. In modern societies we believe an enriched environment is one in which there is one caregiver for every four children. This, says Perry, is one sixteenth of the relational ratio of HGSB. The risk in day care may also be down to its ‘impersonal’ nature and the fact that non-kin are likely to be less attuned to the child than kin (Narvaez et al, 2013). All of this indicates the importance of intervening to make these environments less stressful for young children.
Gender
Neurological research shows the cerebral maturation is slower in males than females and therefore boys are more at risk than girls in development (Schore, 2019a). Differences between male and female susceptibility are constant across cultures and time: Women are more likely to get depressed while men are more prone to schizophrenia, antisocial behaviour and addictions. Men are more likely to express unhappiness through externalising disorders while women are more prone to ‘internalising’ (e.g. eating disorders). The maturational delay in boys and deficits in social and emotional functioning of the early developing right brain makes them more prone to externalising psychopathologies. It is becoming clear that ‘making a male’ is fraught with danger.
Boys are more at risk for autism, schizophrenia, ADHD, and conduct disorders (Schore, 2019a). All of these disorders have increased ‘significantly’ in recent years. The stress regulating circuits of the male brain develop more slowly in the prenatal, perinatal and postnatal critical periods. As a result, developing boys are more vulnerable for longer to stressors in the social environment like attachment trauma, as well as toxins in the environment like pesticides and plasticizers that impair the development of the right brain.
The origins of male and female dominant psychopathologies that emerge later in life are rooted in differences between boys and girls that are present before the manifestation of clinical problems (Schore, 2019a). Males are more vulnerable to neuropsychiatric disorders that emerge developmentally while females are more prone to ones that appear later. ADHD is the most common brain disorder of childhood impacting one in ten children in the US, with boys 2.5 times more likely to be diagnosed. It has been suggested that this indicates there is an epidemic of brain-based disorders.
Boys are at risk in the womb – even in utero the male foetus shows different rates of brain maturation and stress reactivity (Schore, 2019a). There is a need to move developmental etiological models to ‘life before birth’. Foetal programming hypothesis is widely accepted. The developing foetus goes through rapid developmental changes and is vulnerable to ‘organising and disorganising environmental influences’ during prenatal sensitive periods (p.90). These leave ‘permanent imprints’ on later gender differences for both healthy emotional development and vulnerability to psychiatric disorders. Research shows the male foetuses are more vulnerable to inadequate nutrition. Preterm boys have significantly higher levels of developmental disability than girls. Foetal distress during labour is also more common in males. This increased risk for new-born males continues during later development. Males are also more vulnerable to early life immune challenges which continues throughout life. There is now agreement that immune maturation in prenatal and perinatal periods establishes a person’s trajectory for health and susceptibility to disease throughout the lifespan.
Exposing new born males to separation stress causes an acute cortisol reaction and is therefore a severe stressor (Schore, 2019a). Repeated separations cause hyperactive behaviour and changes prefronto-limbic pathways – areas implicated in mental disorders. Long-term outcomes of stressors on the male brain include impaired emotion processing, behavioural flexibility and executive control. Regulated levels of moderate stress facilitate healthy brain development.
Prenatal maternal stress leads to high levels of corticosteroids being released into the bloodstream causing stress hormones to cross the placenta (Schore, 2019a). The developing male’s ‘extreme sensitivity’ to stress in the social world and hormonal changes make him more vulnerable to early child abuse and neglect as well as extreme developmental stressors in the maternal-infant dyad that alter the development of prefronto-limbic pathways that link with the HPA axis. Prenatal and postnatal maternal-infant interactions programme the HPA axis and severe stress in early life permanently impair this stress regulating system across the lifespan, which compromises the future physical and mental health of the person. Neurodevelopmental disorders, it has been argued, is the outcome of alterations in set points in the endocrine systems and the HPA axis.
Infant boys show ‘significantly’ more disorganised attachment behaviours and the conclusion has been drawn that gender plays a role is disorganised behaviour in high-risk groups (Schore, 2019a). The increased risk of the developing male brain means that intense postnatal stressors can be seen as a ‘significant etiological scenario’ for vulnerability to male-dominant externalising psychopathologies that emerge in adolescence. Adolescence, similar to early periods of prenatal and postnatal testosterone surges, witnesses a ‘steroid-dependant organisational re-modelling of the developing male brain’ (Schore, 2019a, p.107). It is a time when exposure to gonadal hormones alters the developmental trajectory to influence outcomes in adulthood. Puberty, therefore, is a time of ‘intense neurostructural and endocrine changes’ (Schore, 2019a, p.108). Conduct disorder, a typical male-dominated externalising disorder, increases at this time. Depression increases in females from mid-puberty onwards but not in males.
The transition to adolescence is a period of risk for boys, in particular those who have experienced foetal or postnatal dysregulation of testosterone as a result of trauma (e.g. abuse and neglect), toxins and prenatal alcohol (Schore, 2019a). A history of abuse or neglect is common in severe conduct disorders creating a disposition towards violence. The delayed maturation of the emotion processing and cortical system in males from earlier development is still in operation in adolescence when structural deficits are reactivated when cortical and limbic circuits are being re-modelled. This protracted cortical maturation leads to longer periods when detrimental influences are being accrued.
Schore claims that all males are at higher risk as a result of their slower rate of maturation conferring on them a protracted period of vulnerability. However, even within the male population there is a large degree of variability in vulnerability as some are exposed to multiple risk factors throughout their development (poverty, violence, maternal stress etc.) while others are not. In addition, the differential susceptibility model suggests that the impact of the environment upon the child can be moderated by temperament in both directions – those highly susceptible to negative influences may respond most to positive influences i.e. therapeutic intervention (Belsky and Pluess, 2009). Being able to identify these sensitive individuals early could help in prevention. It could be argued that, due to the widespread destruction ‘externalising’ psychopathologies create in society (i.e. more harm for more people) targeting high risk boys perhaps should be given particular priority.
Violence
The mental health field needs to move from later intervention to early prevention in order to deal with the problem of violence in society (Schore, 2003). ‘Ghosts from the nursery’ erupt in tragic violent encounters at later stages of development. These ‘ghosts from the nursery’ are “enduring right brain imprints of the nonconscious intergenerational transmission of relational trauma” (p.149). Practical solutions must involve providing optimal socio-emotional environments for larger numbers of infants.
The underlying causal mechanisms of violence are operational in childhood (Schore, in Siegel and Solomon, 2003). An increasing body of evidence shows that traumatic childhood experiences are at the root of adult violence. When there are violent offenders still in their first decade it tells us that we must look even earlier for the causal roots – to the very beginning of life.
Most traumatised and emotionally neglected children do not turn into violent criminals or sociopaths (Schore, in Siegel and Solomon, 2003). The presence of positive relationships (with a teacher, grandparent, someone in the community) can protect against these outcomes. Those who lack this may seek to connect through destructive or disturbed relationships. Even a single, attuned positive relationship can turn someone away from this trajectory towards a sociopathic or borderline personality.
Treatment and intervention needs to begin much earlier in life in order to protect against violence (Schore, in Siegel and Solomon, 2003). This should happen in pregnancy and continue through the prenatal and postnatal period of the brain growth spurt in the first two years of life. This involves establishing ‘standardised, reliable diagnostic protocols’ that identify maternal and infant risk factors and dyads that experience strong and prolonged negative affect (p.146). These should also take gender into account.
Autism and attachment
The mental health field agrees that infantile autism and disorganized insecure attachment are the most severe examples of early dysregulated social and emotional development (Schore, 2019a). Altered right brain maturation is evident in these psychopathologies. There is a call in the autism and attachment literature for research-informed interventions that can access the mother-infant dyad in the early period more effectively. Studies show that autism develops during foetal development as a result of genetic and ‘untoward intrauterine influences of the social and physical environment’ (Schore, 2019a, p.250). Autism is the result of ‘altered connectivity and developmental derangement of the right brain’ (Schore, 2019a, p.251). In essence, autism is a ‘severe impairment of the right-lateralised, implicit…self-system that acts unconsciously and automatically’ (Schore, 2019a, p.251). Schore argues that deficits in early spontaneous play between mother and infant are central to the psychopathogenesis of autistic disorders. In addition to attachment researchers, autism researchers are emphasising the importance of earlier identification so that treatment can be implemented at a very young age when the brain is most plastic, hold the promise of lessening or preventing the lifelong challenges that arise with autism. Early assessment of high-risk dyads can create interventions that develop the mother’s implicit ability to interactively regulate affect and create a growth facilitating environment in which the infant’s right brain can develop. The need for early prevention includes the prenatal period. Schore quotes Rutter who noted that in autism there is a relative lack of bonding and attachment behaviour. Most children who experience attachment disorders do not develop autism disorders but both may share common psychoneurobiological etiological factors.
Models of autistic aetiology are moving towards the ‘interactive relational model’ used by other developmental neuropsychiatric disorders – infant interactions with the socioemotional environment (Schore, 2019a). The attachment relationship has a direct influence on the development of the autistic brain. Children with autism have an enlarged right amygdala and a body of research shows that these infants and toddlers experience a chronic state of fear in the first two years that needs to be assessed. The disorganised infant demonstrates ‘sustained withdrawal’ manifesting as frozen and absent facial expressions, avoidance of eye contact, immobile activity, lack of vocalisation, lack of relating, and a sense that the child is beyond reach. Withdrawn social behaviour can be seen at 2 months in autism, chronic or severe pain, failure to thrive and posttraumatic stress disorder.
Caregivers of autistic infant’s, in response to hypoactive behaviour assume the infant needs more stimulation and adopt a hyper-stimulating style, which, says Schore, may increase dissociative withdrawal (Schore, 2019a). On the basis of this there has been calls for assessment/ screening in the first 6 months and ‘parent-infant’ training in the second trimester. In the second trimester there is a documented reduction in affectionate touch which may be a response to the infant’s reduced motor and vocal development. This ‘non-synchronic’ motor-vocal pattern may inhibit the development of reciprocity. This reduced affection may be a maternal coping mechanism of defensive withdrawal as a response to the ‘intense stressor’ of an emotionally unresponsive infant. Schore notes that it is often overlooked that a dysregulated infant may be a source of stress for the mother. The above describes the dynamic in an autistic infant-parent dyad but it holds a lesson for the development of all disorders. Brisch (2014) observes how parents often don’t seek help until problems have become chronic. Interventions that support dyads from the beginning and continue through the first couple of years can ensure that problems are nipped in the bud and don’t develop to the point where the dynamic becomes harder to shift.
The primordial aetiology of autism, attachment disorders and all early forming psychiatric disorders occur in universally shared prenatal, perinatal and postnatal environments (Schore, 2019a). In disorganised attachments, right amygdala alterations may lead to epigenetic mechanisms linked with stressful perinatal and postnatal social environments. Attachment disorders involve ‘delayed connectivity’ or immaturity of limbic-autonomic circuits of the right brain. In autism, developmental neuropathology is expressed in all three regulatory control systems. Chronic failures of interactive arousal regulation manifest as deficits in intersubjectivity and dysregulated fear-driven states in the infantile autistic brain.
Schore highlights the need not just to able to highlight at risk populations but also the importance of tracking and monitoring the attachment dyad in real developmental time. The importance of beginning assessments and interventions in pregnancy is repeatedly highlighted but this must continue throughout the first two years of life, focusing on how the attachment relationship is functioning. Screening and assessment is crucial to identify problematic patterns early on so that interventions can be provided to prevent these developmental pathways from becoming engrained. We will turn next to the issue of clinical assessments that can identify where problems may exist and inform intervention strategies.
References
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Bloom, S. L. (2013). Creating sanctuary: Toward the evolution of sane societies. Routledge.
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Lieberman, A. F., Diaz, M. A., Castro, G., & Bucio, G. O. (2020). Make room for baby: Perinatal child-parent psychotherapy to repair trauma and promote attachment. Guilford Publications.
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